Adult foster care is still allowed in Wisconsin
As summarized from the 2018 Compendium of Residential Care and Assisted Living Regulations and Policy:
Adult Foster Care. The Department also licenses adult family homes, which are private residences in which the care provider–whose primary domicile is this residence –furnishes care and maintenance above the level of room and board to 3-4 adults who are not related to the licensee. Homes serving 1-2 individuals do not need to be licensed but if they want to receive public funding, they are regulated by individual county Human Services departments. No more than 7 hours per week of nursing care per resident may be provided in this setting. Regulatory provisions for adult family homes are not included in this profile but a link to the provisions can found at the end.
https://aspe.hhs.gov/sites/default/files/private/pdf/110646/15alcom-WI.pdf#page=1
Homes serving 3-4 adults must be licensed “Adult Family Homes”, but they are distinguished from “Homes serving 1-2 individuals”, so I will refer to them by quoting “Homes serving 1-2 individuals”. “Certified 1-2 Bed Adult Family Homes” are named separately in https://www.dhs.wisconsin.gov/regulations/afh/1-2bed/index.htm, but these certified homes are not within the state code’s definition of an Adult Family Home, which is a “residence for 3 or 4 adults”, 50.01(1)(a)1, not counting the operator of the home. There are certain exceptions allowing for more in the event siblings are being cared for. The label “Certified 1-2 Bed Adult Family Home” is used, not because it is found in state law, but because of Medicaid reimbursement purposes. Medicaid will not reimbursee the state for payments made to caregivers in uncertified adult foster homes.
A graph in the Door County Comprehensive and Farmland Preservation Plan, at the top of https://www.co.door.wi.gov/DocumentCenter/View/8095/Chapter-2-Issues-and-Opportunities#page=5, projects a large increase in the “75-79”, “80-84”, and “85+” age brackets by the year 2050. Likewise, https://www.greenbaypressgazette.com/story/news/local/2024/10/16/elderly-population-in-wisconsin-is-rising-elder-care-workers-needed-study-says/75568551007 states that Wisconsin will need an additional 33,000 total licensed nursing beds by 2023. A nationwide graph of the nursing home population shows a steady increase since 2019: https://www.zippia.com/advice/nursing-home-statistics.
There is a list of possibilities for housing elderly people in https://www.co.door.wi.gov/DocumentCenter/View/8093/Chapter-4-Housing-Characteristics#page=15:
Other types of housing for senior citizens, the physically disabled, and mentally/emotionally disabled include assisted living apartments, Community-Based Residential Facilities (CBRF), nursing homes, and Residential Care Apartment Complexes (RCAC).
This chapter of the draft plan omits the state Department of Health Services’ option for placing elderly people in “Homes serving 1-2 individuals”. Referring back to the quote at the beginning of this post, these homes “do not need to be licensed but if they want to receive public funding, they are regulated by individual county Human Services departments.”
The detailed discussion in https://www.co.door.wi.gov/DocumentCenter/View/8088/Chapter-9-Community-Facilities-and-Utilities#page=23 spends two and a half pages covering various residential care options. It mentions “Adult Family Facilities”:
AFHs are facilities where three or four adults unrelated to the operator reside and receive care, treatment, or services that are above the level of room and board, including up to seven hours per week of nursing care per resident. …
However, it too omits “Homes serving 1-2 individuals”. The planning document would be more complete if it stated that adult foster care, either certified for Medicaid funding purposes or not, is one of the legally permissible options available in Wisconsin.
This omission contrasts with the visibility of a campaign, https://unitedwaydc.com/child-care-initiatives, to recruit more people willing to “care for one or two more children in your home”. Care at the scale of “one or two” each per home is being promoted for children, but not elderly people.
Some elderly people end up being placed in institutions outside the county; there is no absolute right to remain in the locality where one previously lived. How many of them are unaware that state law allows for the possibility of adult foster care in “Homes serving 1-2 individuals”? Or if specific questions are asked, is the impression ever given that this option is for people with disabilities, but not also for elderly people seeking an alternative to institutionalization?
The table on https://wha.org/2023-DHS-BakerTillyLTCReport.pdf#page=46 states that 15.4% of nursing home providers surveyed stated that “Distance of the referral from the facility/family” was a challenge for them with accepting Medicaid-waiver referrals, but for providers of certified 1-2 Bed AFH [Adult Family Homes] and 3-4 Bed AFH, the percentages of providers reporting this challenge were only 7.1% and 5.1%, respectively. Also, the adult family home providers cited the lack of open beds as a challenge at 46.5% and 50.4%, while the percentage of nursing home providers reporting this challenge was 26.0%.
There is a preference in the state Health Services code, such as DHS 94.07, DHS 83.32(3)(L), and DHS 132.33(2), for people to be placed in “least restrictive” forms of care.
Hourly care limits can be used in order to figure out which of the four options, Adult Family Homes, Community-Based Residential Facilities, Residential Care Apartment Complexes, and nursing homes, is least restrictive for the amount of care needed.
Someone who prefers to remain in a less restrictive setting could be transferred to a more restrictive setting such as a nursing home, if the required amount of care was greater than the maximum limit. For example, the time limit on care in an Adult Family Home [for 3-4 persons] is seven hours per week, as mentioned in the quote at the beginning of the article.
But neither “Homes serving 1-2 individuals” or “Certified 1-2 Bed Adult Family Homes” are subject to a statutory hourly limit for the amount of care. They do not legally count as a Adult Family Homes under 50.01(1) because they do not care for three or four people. The implementation of adult foster care could be interpreted more conservatively, such as described by Jane Huseth, https://doorcounty.substack.com/p/foster-homes-needed-for-elderly-residents-1970, who sharply differentiated between nursing home care and adult foster care. Yet the state’s code does not state this. Another flexibility is that there is no restriction on combining adult foster care with adult day care services.
Some people have a higher degree of needs, such as requiring two people’s assistance to bathe or use the toilet, and would not be able to live in an adult foster home. But an unknown proportion of the overall institutionalized elderly population today, and in the future, could instead live in adult foster “Homes serving 1-2 individuals” if they so desired and the funding and capacity existed for it.
Ensuring this would be a political undertaking. At the federal level, Medicaid funding is restricted by the certification requirements. If adult foster care was funded at the county or state level by non-federal tax money, it could be expanded more easily. One way to expand adult foster care would be to use non-federal funds initially to reduce red tape, while working to get uncertified adult foster homes certified so that Medicaid funds can be used in the future.
What if adult foster care became a more common and usual practice than it is today? In the long run this might challenge generalized attitudes towards institutionalized care.
A previously posted article, https://doorcounty.substack.com/p/ss-peter-and-paul-began-as-mission-had-institute-1962, describes an institution which once cared for orphans and semi-orphans in Door County. But today things are done differently for children who are not being cared for by foster parents. A list of group homes in Wisconsin, https://dcf.wisconsin.gov/files/cwlicensing/pdf/gh.pdf, includes some which house minors. There aren’t any group homes for minors in Door County, so when there isn’t enough foster care available, social workers may end up taking minors with them to work. The situation isn’t unlike what Huseth described for adult foster parents, who needed to be willing to bring their one to two elderly people “on rides — both for business and pleasure”.
Parents in foreign countries who are impoverished are sometimes led to believe that their children will receive a superior education or diet in an orphanage. They may return to visit their children on weekends, and expect to take them back out of the orphanage eventually. The degree of shame or stigma that would be experienced by American parents choosing to place their children in an orphanage is apparently lacking for these foreign parents.
For now, Americans are more willing to institutionalize elderly people than children. But if attitudes continue to change, people might make different choices in the future.
Expanding the use of “homes serving 1-2 individuals” could go a long way towards solving the problem of the lack of nursing home workers described in the lower part of the Green Bay Press-Gazette article. That article is based on a study, https://www.wpr.org/wp-content/uploads/2024/10/On-The-Brink.pdf#page=3, which predicts that, unless minimum staffing laws are watered down, “facilities would need an additional 9,900 registered nurses, CNAs, and home health/personal care aides by 2030”.
But could the future see a campaign to recruit more people willing to “care for one or two unrelated elderly people in your home”? Or will this possibility be ignored, with instead only a call to boost the number of professional caregivers?
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